Janya Mercado

**** ********* ******, *** *******, CA. 90063 323-***-**** janyavaldez74@gmailcom

● Bilingual: Fluent in Spanish

● Proficient with computer software such as Microsoft Office applications (MS Word, Excel, Access) EZCAP, NextGen, EMR

● Experienced over 10 years in Healthcare Industry (Corporate Setting), familiar with all Line of Business

(HMO, IPA, Medi-Cal, Medicare, Medicare Railroad, CCS)

● Knowledgeable in Member Eligibility (Complaints & Appeals)/Retention and Provider Enrollment Authorizations / billing procedures

Experience

Student & Family Resources Navigator - LAUSD 2021 to Present Casemanage services within a Healthy Start Program school-based health clinic Wellness Center and community resources .Conducts intake and follow-up meetings with identified clients such as homeless/foster youth families. Provides parents, students and staff with resource information/referrals to mental health or other services designed to meet specific social emotional academics. Outreach and enrollment efforts include health insurance programs such as low to no-cost health insurance programs such as Medi-Cal and Covered California.

Leads the organization and implementation of local Healthy Start Program and Healthy Habits (Nutrition Education).

Collaborate in meetings such as school site Student Success Teams SST Student Support and Progress Team SSPT Coordination of Services Team. Attend meetings that include school administrators : Crisis Meetings, Attendance, Mental Health.

Alma House Assisted Living Home -November 2019- to March 2020 (Per Diem – Weekends/ Holidays) Assisted Living in everyday activities for the Intellectual Disabled, including transportation, assistance with medications, Supervise and assist in preparing meals, housekeeping. Overnight watch. The goal, while in assisted living, is for the residents to become more independent with their own living arrangements.

Keck-USC /USC Care Medical Group - Provider Enrollment Specialist (February 2018 to October 2020) Responsible for preparing and submitting credentialed applications and supporting documentation for the purpose of enrolling new and continuing providers. Followed up closely on the status of provider's application to Government sites. TES Edits (Provider Claims) - GECB System

Familiar with Government websites (i.e. from Centers of Medicare (CMS), Department of Health Care Services

(DHCS-Medi-Cal), Enrollments to Children's Medicaid Services (CCS), Medicare Railroad. Syner Med -Authorization Coordinator (OBGYN, PEDS) (February 2017-June 2017

(OBGYN, PEDS) Authorizations: Modify CPT codes, Data Entry request clinical notes from providers, update patient's file. Follow up with Urgent requests. Familiar with EHR/EMR Care1st Health Plan – Member Representative (July 2013-February 2017) Eligibility/Enrollment: Assisted members with inquiries regarding plan benefits and coverage, including provider changes. Duties also included; (EOB) mailed to members as requested. Responsible for thorough follow-up and completion of all member and provider inquiries or requests; including member enrollments, eligibility confirmation. Worked on special assignments or projects as requested. Conducted Annual Medicare Enrollments and changes to their Medicare plans.

Authorizations /Claims: Responsible for submitting patient's denied claims, modifying authorization with complete and accurate documentation

Complaints/ Grievance / Appeals: follow-up of all member issues, Grievances and Appeals in a timely and efficient manner.

AltaMed Health Services Corporation - Patient Coordinator (September 2009- July 2013) Customer Service: Initiate a high volume of outbound phone calls to members for retention efforts Medi-Cal through the Redetermination process. Submitted Authorization, modifications. Complaints /Grievance: Responsible for taking complex member complaints and grievances and overturn/close them on a timely manner by the health plans and government programs policy. Member retention: Conduct welcome calls and schedule the first initial physical assessment to our new FQHC and Non-FQHC enrollee to improve HEDIS measures. Identify and coordinate enrollment from one managed care plan to another when members lose eligibility in one plan (i.e., from Medi-Cal, Medi-Care to Healthy Families. Provide information to government agencies (DPSS, LACDHS, SDHS) to release Medi-Cal members from eligibility hold status. Maintain reports on monthly activity (e.g. On Hold, Re-Determination, CCS Dis-Enrollment, Senior Welcome Calls, and SPD Welcome Calls, Dual Eligible activity). Bingham Mccutchen Law Firm LLP - Lead Office Clerk (2003-2006) Performed general office duties; answering multi line phone, Client records/filing court case records, assisted the legal research team by scanning and copying. Set Court appointments for Attorneys, Conference room setup; maintained a log of incoming court filings, subpoenas and packages. Estrella Realty - Office Administration (2003 and 2006 to 2009) Assisted in every facet of running office, including but not limited to, clerical duties, filing, calendaring appointments, heavy client contact (customer service), and data entry; assisted in filing paperwork for loans. Answered incoming calls and questions from current and potential clients, agents, and other business associates. Tracked and documented all business-related communications, store/file according to company standards. Staff, management, brokerage professionals, and Property Management. LAUSD: Teacher Assistant /Tutor 1998 – 2003

Parks Huerta Primary Center - Teacher Assistant I Tutor 2003-2004 Performed one-on-one tutoring with students in varied subjects as deemed necessary to develop their academic skills. Collaborated with parents to achieve success for their children's educational needs within the home and school.

Pio Pico Span School – Teacher Assistant / After School Tutor 2001-2003 Assisted the Literacy Coach with full responsibility in directing reading workshops. Assisted in the educational development of children by aiding the Lead teacher in all classroom lesson plans and activities. Created and facilitated various lesson plans to implement throughout the academic year by enhancing students' values and morals by implementing several positive behavior classroom activities. Gardena Alternative Education Center (AEWC) 1998-2001 Administration: Facilitated student enrollment, pre-assessment and post educational requirements. Assisted director within the daily functions of our program, including parent teacher conferences. Established an academic advisement program for high-school dropouts and students in danger of failing dropout prevention and recovery strategies. Assisted teens with IEP goals within a group setting with daily assignments and created their individual education plan, by customizing each program, course, and curriculum to best meet each student needs.